Provider Demographics
NPI:1407120967
Name:RUSSELL, JESSICA JEAN (LMT)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:JEAN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:JEAN
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:219 S 4TH ST E
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2725
Mailing Address - Country:US
Mailing Address - Phone:406-493-9507
Mailing Address - Fax:
Practice Address - Street 1:219 S 4TH ST E
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2725
Practice Address - Country:US
Practice Address - Phone:406-493-9507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT670225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist